Longer Diagnosis-surgery Duration Is Associated With an Increased Risk of Early Postoperative Complications for Crohn's Disease: A Retrospective Study

Longer Diagnosis-surgery Duration Is Associated With an Increased Risk of Early Postoperative Complications for Crohn's Disease: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Longer Diagnosis-surgery Duration Is Associated With an Increased Risk of Early Postoperative Complications for Crohn's Disease: A Retrospective Study Xuanyi Chen, Siqi Zhang, Fanru Shen, Yuan Shi, Sailiang Liu, Yihua Jin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1142302/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Early postoperative complications(ePOCs) frequently occur in Crohn’s patients after surgery. The risk factors of ePOCs for Crohn’s disease (CD), however, remain controversial. We aimed to assess the incidence and risk factors of ePOCs in CD patients after surgical resection. Methods: The retrospective study was conducted on 97 patients undergoing surgeries between January 2010 and September 2019 for Crohn’s disease in a tertiary hospital in China. Results: In total, 33 patients (34.0%) experienced ePOCs, including 11 intra-abdominal septic complications (11.3%) and 1 postoperative death (1.0%). Severe complications (Dindo–Clavien III–IV) were seen in 8 patients (8.2%). In multivariate analysis, diagnosis-surgery duration exceeding 6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count 10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031)were identified as independent risk factors for ePOCs. Preoperative exposure to anti-tumor necrosis factor (TNF) agents (P=1.00) were not associated with a higher risk of ePOCs. 34.0% of CD patients developed ePOCs after surgical resection. Conclusions : Diagnosis-surgery duration exceeding 6 months, serum platelet count 10U/L were associated with an increased risk of ePOCs. Preoperative exposure to anti-TNF agents were not associated with a higher risk of ePOCs. Gastroenterology & Hepatology Crohn’s disease diagnosis-surgery duration postoperative complications risk factors retrospective study Introduction Crohn’s disease is an immune-mediated inflammatory bowel disease characterized by chronic skip lesions that can affect any part of the gastrointestinal tract, leading to bowel damage and disability 1 . As a global disease, its worldwide incidence and prevalence are steadily increasing with time 2 . Since the 1980s, the introduction of biological therapies such as monoclonal antibody against tumor necrosis factor (TNF) and vedolizumab changed the paradigm of treatment, leading to improved response and remission in patients 3–5 . Though the risk of surgery in patients with Crohn’s disease shows a decreasing trend thanks to advances in pharmacotherapy, about 50% of patients develop complications refractory to medical therapy and will still require surgery within 10 years after diagnosis 6 . According to the literature, early postoperative complications(ePOCs) could occur in up to 37.5% of CD patients after surgery 7–13 . Therefore, numerous studies have tried to explore the risk factors related to ePOCs which include low albumin level, penetrating disease, laparoscopic approach, preoperative exposure to steroids 7–13 . On the one hand, data remain conflicting regarding on some variables such as preoperative use of anti-TNF agents 8–13 ; on the other hand, many variables are not included in the preexisting studies such as the diagnosis-surgery duration and some preoperative biological data. Therefore, better knowledge of risk factors for ePOCs of CD would help to define a high-risk population where prevention for postoperative complications would be beneficial. The purpose of this study was to reliably identify incidence and risk factors of ePOCs after surgery for CD in a retrospective cohort from a high-volume tertiary center to improve postoperative outcomes. Methods 2.0 Patient selection This was a single-center retrospective study based on a database of 97 patients who underwent surgical resection for primary or recurrent Crohn's disease between January 2010 and September 2019. Patients pathologically diagnosed with Crohn's disease intraoperatively were included. Exclusion criteria were surgeries without pathological examination such as perianal surgery and abscess drainage alone, and missing or invalid data precluding analysis. 97 patients were eligible for analysis after these exclusion criteria were applied. This study was approved by Renji hospital’s research and ethics committee (KY2019-180). 2.1 Data collection Data were retrieved in a standardized format by expert gastroenterologists from Renji hospital medical records. Demographic data (age, sex, age at diagnosis, diagnosis-surgery duration), clinical data (disease location and behavior according to the Montreal classification 14 , presence of perianal manifestation and multiple lesions, history of intestinal resection and anal fistula surgery, and the indications for surgery), data on medication (steroids, IFX, 5-ASA, MTX, Azathioprine, Tacrolimus use within 2 months before surgery and their use history), preoperative laboratory testing (including serum hemoglobin, leukocyte, platelets, C-reactive protein, erythrocyte sedimentation rate, albumin, prealbumin, alanine transaminase, glutamic-oxalacetic transaminase, gamma-glutamyl transpeptidase, direct bilirubin, total bilirubin, urea, creatinine, uric acid, Na ion, K ion, procalcitonin levels), and operative data (emergency surgery, surgical approach, anastomotic configuration, length of hospital stay) were collected. All operations were performed by specialized surgeons from colorectal surgery department in Renji Hospital. And the surgical techniques (including surgery approach, anastomosis vs. stoma, etc.) were decided on a per-patient basis and left to the discretion of the surgeon based on patient’s disease characteristics and intra-operative findings. 2.2 Evaluated outcomes Surgical outcome was determined by postoperative complications and follow-up. Early postoperative complications(ePOCs) were defined as any deviation from the normal postoperative course within 30 days after surgery, and classified into three categories; (i) intra-abdominal septic complications (IASC)(including abdominal abscess and anastomotic leak confirmed radiologically), (ii)extra-abdominal septic complications(including wound infection, pneumonia and septic shock) and (iii)non-septic complications(including enterocutaneous fistula, hemorrhage, bowel obstruction, gastric retention, thrombosis, malnutrition, anemia). Specifically, abdominal abscess was defined as an abdominal mass or an area of localized abdominal tenderness in a feverish patient, confirmed by radiological evidence; bowel obstruction was defined as bowel dysfunction associated with clinical manifestations such as abdominal distention or vomiting. Data on aforementioned ePOCs were collected in a standardized format by appropriate laboratory tests and/or imaging modalities and were reviewed in detail. The severity of ePOCs was graded as I, II, III, IV, or V, according to the Dindo–Clavien classification 15 . Grades I, II were considered to be minor complications while grades III-V were considered to be major complications. Furthermore, the length of hospital stay was also noted. 2.3 Statistical analysis The SPSS program version 21 was used for data analysis. Categorical variables were represented as the number (percentage). The primary endpoint was the occurrence of ePOCs. Normality of distribution for quantitative variables was evaluated using the Kolmogorov-Smirnov tests. Normally distributed variables were described as mean value (±standard deviation), whereas non-normally distributed ones were presented as median (25th -75th interquartile range [IQR]). In order to identify the risk factors of ePOCs, univariate and multivariate analyses were performed to examine the relationship between the occurrence of ePOCs and variables related to the patient characteristics and their clinical parameters. Univariate analysis was conducted using Pearson’s chi-square test or Fisher’s exact test to compare categorical variables, as appropriate. All variables associated with P values <0.1 were included in a binary logistic regression model, expressed as the odds ratio (OR) (95% confidence interval (CI)). All P-values were 2-sided and P-values <0.05 were considered statistically significant. Results 3.0 Demographic and clinical characteristics From January 2010 and September 2019, 97 patients underwent surgeries for CD. Their demographic and clinical characteristics at the time of surgery are summarized in Table 1 . Our population had a median age of 43 years (IQR 37-52 years), and included 64 male patients (66.0%). According to Montreal classification, the majority of patients (n=57, 58.8%) were diagnosed with CD between 17-40 years old(A2); 34 patients (35.1%) presented with disease localized in ileum(L1) and 26 patients (26.8%) had colon(L2) involvement only; clinical disease behavior was non- stricturing/non-penetrating in 22 patients (22.7%), stricturing in 41 patients (42.3%) and penetrating in 34 patients (35.0%). Perianal lesion was detected in 27(27.8%) cases. 15(15.5%) patients had a history of abdominal surgery. 13(13.4%) patients had previously undergone anal fistula surgery. 3.1 Medications The medication history and preoperative (within 2 months before surgery) medical treatment are specified in Table 1 . For patients’ medication history, 34 (35.1%) patients had been treated with steroids, including either systemic steroids or budesonide. 41 (42.3%) patients had received 5-aminosalicylic acid, and 23 (23.7%) patients had received azathioprine in their medical records; fewer patients had been treated with infliximab (8, 8.2%), methotrexate (2, 2.1%), tacrolimus (3, 3.1%). As for preoperative medical treatment, 19 patients had received steroids within 2 months before surgery, and 26 (26.8%) patients had been treated with 5-aminosalicylic acid (with 1 on infliximab, 9 on azathioprine and 1 on tacrolimus). 3.2 Preoperative laboratory testing Laboratory tests at the time of surgery are detailed in Table 1 . In the routine blood tests, the median leukocyte count was 7390/mm3 (5100–12500), the mean hemoglobin level was 11.2g/dl, and the median platelet count was 245×109/L (195–341). The median C-reactive protein level at surgery was 6.38 (1.73-21.30) mg/dl while the median ESR level was 17(10.25-37.5) g/dl, and the median prealbumin level was 155.85mg/L (105.73-221.75). A minority of patients (n=19, 19.6%) had poor preoperative nutritional status defined as preoperative serum albumin <30 g/dL. For liver function related index, the median serum level of ALT, AST, and GGT was 11(7.0-18.3), 14(11.0-17.25), and 17.3(10.45-32.25) U/L, respectively (3.9 and 9.6 umol/L on median serum direct and total bilirubin). For renal function test, the median serum creatine and uric acid level was 59.1(47.5-71) and 216.45(96.49), respectively. Data regarding serum procalcitonin level were only collected in 28 cases, most of which were >0.02 ng/ml (n=22, 75.9%). 2.3 Surgical data The median duration from diagnosis to surgery was 4(0-25.5) months, and more than 41.2% patients did not undergo surgery until 6 months after diagnosis. Emergency surgery was performed in 23(23.7%) cases; laparoscopic surgery in 43(44.3%) patients, and anastomosis was preferred in a majority of patients (n=90, 92.8%). The indications for surgery were obstruction in 40 (41.2%), fistula in 10 (10.3%), perforation in 18(18.6%), bleeding in 6(6.2%) and medication-refractory disease in 5(5.2%) cases. The median postoperative hospital stay was 10 days (7–13). 3.4 ePOCs Overall, 42 ePOCs were observed in 33 patients (34.0%), including 25(25.8%) minor complications (Dindo-Clavien grade I/II) and 8(8.2%) major complications (Dindo-Clavien grade III-V) (Table 2 ). Multiple complications occurred in 6 patients (6.2%). Among all the ePOCs, wound infection was the most common ePOC (n=13, 13.4%). IASCs were recorded in 11 patients (11.3%), including abdominal abscess (n=9, 9.3%) and anastomotic leak (n=2, 2.1%). Extra-Abdominal septic complications occurred in 19 patients (19.6%). Bowel obstruction was the most frequent non-septic complication (5.2%), while postoperative hemorrhage and malnutrition were recorded in 1 patient (1.0%). Other non-septic complications included enterocutaneous fistula (1.0%), gastric retention (2.1%), and anemia (1.0%). No thromboembolic complications were observed. One patient died during the 30-day postoperative period. The median length of postoperative hospital stay was 10 days (7–13), which is significantly correlated with the occurrence of postoperative complications(P<0.001). 3.5 Univariate Analyses of the Risk Factors of ePOCs 3.5.1 Demographic and clinical variables. The results of univariate analyses of the risk factors for overall ePOCs in 97 patients undergoing surgery for CD are reported in Table 1 . None of the studied demographic variables was significantly associated with the occurrence of postoperative complications. Significant differences (P< 0.001) were found in the postoperative complication rate between different disease behavior groups according to Montreal Classification. Higher complication rate (52.0%) was observed in penetrating disease compared to non-penetrating disease (27.8%) (P=0.027). Patients with multiple lesions had significantly higher percentage of ePOCs (51.4% vs. 23.3%, P=0.005). 3.5.2 Medications. Steroid use was associated with a higher incidence of ePOCs (41.2%), although statistical significance was not reached (P=0.274); similarly, the administration of steroids within 2 months before surgery showed insignificantly higher percentages (42.1%) of complications(P=0.407). Infliximab use (25% vs. 34.8%, P=0.71) and preoperative infliximab exposure(P=1.00) were not risk factors for ePOCs. Analyses concerning other therapeutic regimens revealed no significant differences in ePOC rates. 3.5.3 Laboratory parameters. Patients with serum platelet count 10 g/L and ePOCs (23.6% vs. 47.6%, p=0.014). Other biological variables associated with significantly higher rates of ePOC include prealbumin level10 U/L(P=0.01) and serum sodium ion level <139 mmol/L(P=0.008). 3.5.4 Surgical variables. The diagnosis-surgery duration exceeding 6 months is significantly correlated with a higher percentage of ePOCs(P<0.001). 7 patients (16.3%) undergoing laparoscopic surgery experienced postoperative complications, compared with 26 patients (48.1%) undergoing open surgery(P=0.001). There is no significant correlation between the indication for surgery and the occurrence of ePOCs(P=0.691). 3.6 Multivariate Analyses of the Risk Factors of ePOCs Factors affecting ePOCs incidence at a significance level of p < 0.1 in univariate analysis were inserted into a binary logistic regression model (Table 3 ). Diagnosis-surgery duration exceeding 6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count 10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031)were identified as independent risk factors for the ePOCs. Table 1 CD Patients’ Baseline Information and univariate analysis of the risk factors for ePOCs (n=97) Clinical Pathological Factors Value P Value Age (yr), m (IQR) 43(37-52) Male, n (%) 64(66) 0.918 Montreal Classification-Age at diagnosis, n (%) 0.887 A1 2(2.1) A2 57(58.8) A3 38(39.2) Montreal Classification- Location, n (%) 0.190 L1 34(35.1) L2 26(26.8) L3 36(37.1) L4 1(1.0) Montreal Classification-Behavior, n (%) <0.001 B1 22(22.7) B2 41(42.3) B3 34(35.0) 0.028 Perianal manifestations, n (%) 27(27.8) 0.571 Multiple lesions, n (%) 37(38.1) 0.005 Previous abdominal surgery, n (%) 15(15.5) 0.595 Previous CD-related surgical resection, n (%) 13(13.4) 0.533 Previous anal fistula surgery, n (%) 13(13.4) 1.000 Previous medication history, n (%) Steroids 34(35.1) 0.274 IFX 8(8.2) 0.712 5-ASA 41(42.3) 0.982 Methotrexate 2(2.1) 0.546 Azathioprine 23(23.7) 0.678 Tacrolimus 3(3.1) 0.266 Preoperative lab index Leukocytes (/mm 3 ), m (IQR) 7.39(5.1-12.5) >10.0, n (%) 31(33) 0.407 Hemoglobin, mean (SD) 112.3(21.66) <110.0, n (%) 40(41.2) 0.720 Platelets (*1000/mm 3 ), m (IQR) 245(194.75-340.75) 10 42(43.3) 0.014 ESR (mm/h), m(IQR) 17(10.25-37.5) >10 36(75) 1.000 Prealbumin(mg/L),m(IQR) 155.85(105.73-221.75) <174 48(53.3) 0.040 Albumin(g/L), m(IQR) 35.2(31.05-40) 30 38.5) 0.720 AST (U/L), m(IQR) 14(11.0-17.25) >20 16(17.8) 0.618 GGT (U/L), m(IQR) 17.3(10.45-32.25) >10 68(76.4) 0.010 Direct bilirubin (umol/L), m(IQR) 3.9(2.4-5.12) >2.4 65(72.2) 0.219 Total bilirubin (umol/L), m(IQR) 9.6(5.5-12.7) >12 23(25.3) 0.541 Urea (mmol/L), m(IQR) 4.4(3.07-5.7) >57 22(24.7) 0.930 Creatinine (umol/L), m(IQR) median (IQR) 59.1(47.5-71) <47 22(24.7) 0.138 Uric acid(umol/L), m(IQR) 216.45(96.49) <150 23(25.8) 0.794 Na+(mmol/L), m(IQR) 139(137-141) <139 49(51.6) 0.008 K+ (mmol/L), m(IQR) 3.9(3.4-4.2) 0.02 22(75.9) 0.646 Preoperative medical treatment (within 2 months before surgery), n(%) Steroids 19(19.6) 0.407 IFX 1(1) 1.000 5-ASA 26(26.8) 0.940 Methotrexate 9(9.3) 0.714 Azathioprine 0(0) ༏ Tacrolimus 1(1) 1.000 Diagnosis-surgery duration (months), m(IQR) 4(0-25.5) >6, n(%) 40(41.2) <0.001 Emergency operation, n(%) 23(23.7) 0.273 Laparoscopic surgery, n(%) 43(44.3) 0.001 Anastomosis, n(%) 90(92.8) 1.000 Indications for surgery, n(%) 0.691 Obstruction 40(41.2) Fistula 10(10.3) Perforation 18(18.6) Bleeding 6(6.2) Medication- refractory diseases 5(5.2) Others 18(18.6) Length of stay in hospitals (days), m(IQR) 10(7-13) <0.001 Table 2 ePOCs in 97 postoperative CD patients n(%) Number of patients having ePOCs 33(34.0) ePOC cases ( n ) 42 Multiple complications 6(6.2) Intraabdominal septic complications 11(11.3) Abdominal abscess 9(9.3) Anastomotic leak 2(2.1) Extra-abdominal septic complications 19(19.6) Wound infection 13(13.4) Pneumonia 5(5.2) Septic shock 1(1.0) Non-septic complications 12(12.4) Enterocutaneous fistula 1(1.0) Bleeding 1(1.0) Bowel obstruction 5(5.2) Gastric retention 2(2.1) Thrombosis 0 Malnutrition 1(1.0) Anemia 1(1.0) Death 1(1.0) Clavien- Dindo Classification Mild complications 25(25.8) Grade I 7(7.2) Grade II 18(18.6) Severe complications 8(8.2) Grade III 6(6.2) Grade IV 1(1.0) Grade V 1(1.0) Table 3 Multivariate Analysis of the Risk Factors of ePOCs (n= 97) Risk Factors Odds ratio (95%CI) P Value Multiple lesions No Reference Range Yes 2.57(0.62-10.61) 0.19 Clinical disease behavior Non- penetrating disease Reference Range Penetrating disease 1.44(0.33-6.34) 0.63 C-reactive protein(g/L) 10 3.15(0.78-12.70) 0.11 Platelet count (*1000/mm 3 ) >300 Reference Range <300 6.74(1.58-28.71) 0.01 GGT(U/L) 10 9.22(1.23-68.99) 0.03 Na+ (mmol/L) 139 0.41(0.11-1.59) 0.20 Diagnosis- surgery duration(months) 6 months 4.07(1.10-15.09) 0.04 Surgical approach Laparotomy Reference Range Laparoscopic surgery 0.34(0.86-1.37) 0.34 Discussion Surgical resection for CD patients is correlated to high ePOC risks. And some serious postoperative complications such as intra-abdominal septic complications occur more frequently in CD than other diseases 16 , necessitating evaluation of the frequency and risk factors of ePOCs for CD. In this retrospective study, 34.0% patients experienced at least one ePOC, wound infection being the most frequent complication. This incidence is comparable with the current literature, ranging from 21–37% 7–13 . The mortality rate was 1.0% and IASCs were recorded in 11.3% cases, in line with previous studies 8–12 . Numerous studies examined the incidence of ePOCs. A retrospective multi-center study( n =231) of an adult cohort in three countries (Japan, Brazil and Italy) reported an overall ePOCs of 24%. Among 55 reported complications, 12% were intra-abdominal septic complications including anastomotic leakage (8%) and intra-abdominal abscesses (4%). Blood transfusion and perforating disease were independent significant risk factors for overall complications and IASCs, respectively 8 . Another more recent retrospective study in Europe evaluated the risk of postoperative complications in 199 CD patients. 62 (31%) patients experienced at least some kind of ePOCs and IASCs occurred in 34 patients (17%). One patient (0.5%) died from septic shock following proctocolectomy. A bivariate analysis revealed that surgical anastomosis and preoperative hemoglobin level of < 10 g/dl were associated with an increased postoperative IASC rate 11 . Due to high rates of ePOCs for CD surgeries, preoperative risk evaluation of complications seems pivotal to patient optimization for surgery 17 . In our study, A diagnosis-surgery duration>6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count 10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031) were significantly associated with a higher risk for ePOCs in a binary regression. As a progressive disease, CD results in cumulative bowel damage over time, leading to irreversible complications 18 . In a population-based study on the CD progression, about 19% of patients had already experienced penetrating or stricturing complications within the first 3 months of diagnosis, but complications occurred in 50% of patients within 20 years after diagnosis 19 , indicating longer disease duration is associated with increasing disease severity. Therefore, rapid and early intervention including medications and surgery may effectively prevent CD progression so as to reduce the risk of adverse complications and healthcare burden 20 . Shorter disease duration is related to a higher response rate to biologic agents in CD patients 21 . Issues regarding on the safety of early surgical intervention for CD patients, however, are still a subject to debate without a clear consensus. Recently published data from a retrospective study with 153 CD patients undergoing elective ileocolic resection in a Greek tertiary center revealed that disease duration was not an independent predictor for POCs: complication rates in those who went on surgery 10 years after diagnosis were 16.1%, 13.9% and 36.4%, respectively, with no intergroup differences in the incidence of POCs 12 . Our series, however, reported a significant correlation between diagnosis-surgery duration >6 months and ePOCs, in accordance with some previous large studies. For example, a retrospective study in France, concerning 592 consecutive patients who underwent surgery for CD, reported that CD duration >2 years is significantly associated with ePOCs(P=0.01) in univariate analysis 10 . We believe that our findings augment the evidence for the negative effect of long diagnosis-surgery duration on the postoperative course of CD patients. Therefore, we recommend early surgery for eligible patients in order to avoid postoperative complications. Elżbieta et al. examined the relationship between CD duration and CARD15 expression, one of the susceptibility genes in CD, and found a significantly higher peripheral mRNA level of the CARD15 in patients with disease duration between 12 and 60 months, compared to patients whose disease duration was <12 months 22 . We speculated that higher CARD15 expression over longer disease duration modified the disease behavior 23 , making it more complicated, thus leading to a higher rate of ePOCs. And further studies are needed to precisely explore the safety of early surgical intervention and its ability to prevent disease progression in CD. It is important to understand how modifiable factors, especially pre-operative lab parameters, affect outcomes after surgical interventions, so that we can identify high-risk CD population for preoperative optimization. Current data concerning these aspects are, however, relatively scarce, focusing mainly on hemoglobin, CRP and albumin level 9,10,12 . Therefore, one of the unique aspects of our study is the evaluation of numerous possible preoperative lab data. In multivariate analysis, serum platelet count 10U/L were found to be independent risk factors of ePOCs. Low platelet counts can serve as an indicator for active CD 24 , which also helps to explain the correlation between low serum platelet count and a higher risk of ePOCs. On the other hand, Jessika et al. 25 determined that the presence of liver test abnormalities, including gamma-glutamyl transpeptidase, was identified as an indicator for complicated CD(HR 2.6, p < 0.0001). And elevated gamma-glutamyl transpeptidase itself suggests abnormal liver function, which might account for a higher risk of ePOCs. Therefore, according to our study, CD patients who are going to be operated but with serum platelet count 10U/L can be better prepared. Abnormal lab values need to be corrected in these patients to improve postoperative safety. Anti-TNF-alpha agents have been used in the treatment of CD, and their efficacy on CD progression has been well demonstrated 3–5 . Early initiation of infliximab within the first 2 years of diagnosis reduces the rate of surgery 26 . However, given its potential impact on wound healing and immunosuppressive properties, a crucial concern is whether patients undergoing major abdominal surgery after anti-TNF drug exposure are at increased risk of early postoperative complications 27 . In our series, previous exposure to anti-TNF agents in CD patients was not a risk factor for ePOCs, in line with most studies. A Mayo Clinic study 28 supported this idea by illustrating no association between infliximab use and early complications after abdominal surgery for CD. A Los Angeles study 27 revealed a higher but statistically insignificant rate of adverse outcomes in anti-TNF detectable versus undetectable group. Another Canadian retrospective case-control study 29 compared postoperative outcomes of CD patients with or without exposure to anti-TNF agents within 180 days of abdominal surgery, but no intergroup difference was found. The most recent, prospective multicentric literature that included serum drug level measures at time of surgery found no association between preoperative exposure to anti-TNF and postoperative complications 30 . Some studies, however, reached contrary conclusions. Antoine et al. 10 in 2018 found that preoperative anti-TNF therapy was a predictor of morbidity after surgery for ileocolonic CD. Some meta-analyses indicated that preoperative anti-TNF exposure was a risk factor of POCs in CD patients 31–34 . Most of the studies have been criticized for not being able to control crucial confounding factors, such as disease severity, nutritional status as well as preoperative corticosteroid use, which make conclusions less convincing: elevated postoperative complication rates may just be a reflection of disease severity and a higher likelihood of poor nutritional status, but not a direct effect of preoperative anti-TNF exposure. More valid data are needed to confirm our results. Our study presents certain limitations. First, the retrospective design indicates that data can only be passively retrieved from patients’ medical records. Therefore, some data are incomplete or even not collected at all, including procalcitonin levels, configuration of anastomosis (end-to-end vs. side- to-side), patients’ smoking status, BMI values, which are presumable risk factors for ePOCs. Secondly, the sample size(n=97) is not big enough due to the single-center design, which may lead to insufficient size of some subgroups (such as patients with anti-TNF preoperative exposure). Thus, detection of differences may be more difficult and some risk factors for ePOCs might be precluded. Finally, we choose patients from a high-level center that managed CD patients with complicated and severe conditions, suggesting poorer prognosis than other patients despite well-trained and experienced surgeons and multidisciplinary teams. However, we believe that our study adds more new and convincing evidence of risk factors of ePOCs in CD patients. In conclusion, the incidence of ePOCs was 34.0% among CD patients undergoing surgical resection. Diagnosis-surgery duration exceeding 6 months, serum platelet count 10U/L were identified as independent risk factors for the ePOCs. And preoperative anti-TNF exposure was not associated with an elevated ePOC rate. Conclusions Overall, we summarized that the diagnosis-surgery duration exceeding 6 months, serum platelet count 10U/L were associated with an increased risk of ePOCs. Preoperative exposure to anti-TNF agents were not associated with a higher risk of ePOCs. As physicians, the interest of the patient should always be well considered, by reducing the diagnosis-surgery duration, which means to get surgery done sooner, will significantly reduce the early postoperative complications, pain and financial burden of the patient. Declarations Ethics approval and consent to participate: All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital. Informed consents were obtained from all subjects involved in this manuscript. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. The data are not publicly available due to some containing information that could compromise participant privacy. Competing interests: The authors declare that they have no competing interests. Funding: The work was supported by the Cultivation Clinical Research Grants from Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine (PYIII20-14 to Yumin Hao). Author contributions: XC and YM participated in the conception, design, drafting of the study protocol, recruitment of participants. SZ, SL and YJ were responsible for data acquisition. XC and SZ participated in the analysis and interpretation of the data. FS, YS and YQ contributed to the revising of the paper. YM and MZ were responsible for the final approval of the version to be published. And all authors agree to be accountable for all aspects of the work. Acknowledgements : Not applicable References Roda G, Chien Ng S, Kotze PG, et al. Crohn's disease. Nat Rev Dis Primers 2020; 6 (1): 22. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012; 142 (1): 46-54 e42; quiz e30. Colombel JF, Sandborn WJ, Reinisch W, et al. Infliximab, azathioprine, or combination therapy for Crohn's disease. N Engl J Med 2010; 362 (15): 1383-95. Adegbola SO, Sahnan K, Warusavitarne J, Hart A, Tozer P. Anti-TNF Therapy in Crohn's Disease. Int J Mol Sci 2018; 19 (8). Argollo M, Fiorino G, Peyrin-Biroulet L, Danese S. Vedolizumab for the treatment of Crohn's disease. Expert Rev Clin Immunol 2018; 14 (3): 179-89. Frolkis AD, Dykeman J, Negron ME, et al. Risk of surgery for inflammatory bowel diseases has decreased over time: a systematic review and meta-analysis of population-based studies. Gastroenterology 2013; 145 (5): 996-1006. Biroulet LP, Loftus EV, Harmsen WS, et al. 490 Postoperative Complications in a Population-Based Cohort of Crohn's Disease. Gastroenterology 2010; 138 (5, Supplement 1): S-70. Yamamoto T, Spinelli A, Suzuki Y, et al. Risk factors for complications after ileocolonic resection for Crohn's disease with a major focus on the impact of preoperative immunosuppressive and biologic therapy: A retrospective international multicentre study. United European Gastroenterol J 2016; 4 (6): 784-93. Fumery M, Seksik P, Auzolle C, et al. Postoperative Complications after Ileocecal Resection in Crohn's Disease: A Prospective Study From the REMIND Group. Am J Gastroenterol 2017; 112 (2): 337-45. Brouquet A, Maggiori L, Zerbib P, et al. Anti-TNF Therapy Is Associated With an Increased Risk of Postoperative Morbidity After Surgery for Ileocolonic Crohn Disease: Results of a Prospective Nationwide Cohort. Ann Surg 2018; 267 (2): 221-8. Iesalnieks I, Spinelli A, Frasson M, et al. Risk of postoperative morbidity in patients having bowel resection for colonic Crohn's disease. Tech Coloproctol 2018; 22 (12): 947-53. Gklavas A, Poulaki A, Dellaportas D, Papaconstantinou I. Risk factors for postoperative complications after elective ileocolic resection for Crohn's disease: a retrospective study. Ann Gastroenterol 2020; 33 (6): 645-55. Kulaylat AN, Kulaylat AS, Schaefer EW, et al. The Impact of Preoperative Anti-TNFα Therapy on Postoperative Outcomes Following Ileocolectomy in Crohn's Disease. J Gastrointest Surg 2021; 25 (2): 467-74. Silverberg MS, Satsangi J, Ahmad T, et al. Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. Can J Gastroenterol 2005; 19 Suppl A : 5a-36a. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240 (2): 205-13. Lipska MA, Bissett IP, Parry BR, Merrie AE. Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J Surg 2006; 76 (7): 579-85. Spinelli A, Allocca M, Jovani M, Danese S. Review article: optimal preparation for surgery in Crohn's disease. Aliment Pharmacol Ther 2014; 40 (9): 1009-22. Pariente B, Mary JY, Danese S, et al. Development of the Lémann index to assess digestive tract damage in patients with Crohn's disease. Gastroenterology 2015; 148 (1): 52-63.e3. Thia KT, Sandborn WJ, Harmsen WS, Zinsmeister AR, Loftus EV. Risk Factors Associated With Progression to Intestinal Complications of Crohn's Disease in a Population-Based Cohort. Gastroenterology 2010; 139 (4): 1147-55. Danese S, Fiorino G, Peyrin-Biroulet L. Early intervention in Crohn’s disease: towards disease modification trials. Gut 2017; 66 (12): 2179. Faleck DM, Winters A, Chablaney S, et al. Shorter Disease Duration Is Associated With Higher Rates of Response to Vedolizumab in Patients With Crohn’s Disease But Not Ulcerative Colitis. Clinical Gastroenterology and Hepatology 2019; 17 (12): 2497-505.e1. Poniewierka E, Neubauer K, Kempiński R, Sadakierska-Chudy A. Disease duration and age influence CARD15 expression in Crohn's disease. Postepy Hig Med Dosw (Online) 2016; 70 : 10-3. Tsianos EV, Katsanos KH, Tsianos VE. Role of genetics in the diagnosis and prognosis of Crohn's disease. World J Gastroenterol 2012; 18 (2): 105-18. Öztürk ZA, Dag MS, Kuyumcu ME, et al. Could platelet indices be new biomarkers for inflammatory bowel diseases? Eur Rev Med Pharmacol Sci 2013; 17 (3): 334-41. Barendregt J, de Jong M, Haans JJ, et al. Liver test abnormalities predict complicated disease behaviour in patients with newly diagnosed Crohn's disease. Int J Colorectal Dis 2017; 32 (4): 459-67. Ma C, Beilman CL, Huang VW, et al. Anti-TNF Therapy Within 2 Years of Crohn's Disease Diagnosis Improves Patient Outcomes: A Retrospective Cohort Study. Inflamm Bowel Dis 2016; 22 (4): 870-9. Lau C, Dubinsky M, Melmed G, et al. The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery. Ann Surg 2015; 261 (3): 487-96. Colombel JF, Loftus EV, Tremaine WJ, et al. Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab or immunosuppressive therapy. Am J Gastroenterol 2004; 99 (5): 878-83. Waterman M, Xu W, Dinani A, et al. Preoperative biological therapy and short-term outcomes of abdominal surgery in patients with inflammatory bowel disease. Gut 2013; 62 (3): 387-94. Adamina M, Fiorino G. At the Crossroads of Caution and Intervention: Anti-TNF Therapy Prior to Elective CD Surgery. J Crohns Colitis 2021; 15 (10): 1778-9. Billioud V, Ford AC, Tedesco ED, Colombel JF, Roblin X, Peyrin-Biroulet L. Preoperative use of anti-TNF therapy and postoperative complications in inflammatory bowel diseases: a meta-analysis. J Crohns Colitis 2013; 7 (11): 853-67. Yang ZP, Hong L, Wu Q, Wu KC, Fan DM. Preoperative infliximab use and postoperative complications in Crohn's disease: a systematic review and meta-analysis. Int J Surg 2014; 12 (3): 224-30. Waterland P, Athanasiou T, Patel H. Post-operative abdominal complications in Crohn's disease in the biological era: Systematic review and meta-analysis. World J Gastrointest Surg 2016; 8 (3): 274-83. Marchal L, D'Haens G, Van Assche G, et al. The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study. Aliment Pharmacol Ther 2004; 19 (7): 749-54. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1142302","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":70576093,"identity":"a8ceaee4-c528-4875-8dd1-9a37e5e616ce","order_by":0,"name":"Xuanyi Chen","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xuanyi","middleName":"","lastName":"Chen","suffix":""},{"id":70576094,"identity":"9b6e12f2-4520-4b3e-9ce5-6000df71401e","order_by":1,"name":"Siqi Zhang","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Siqi","middleName":"","lastName":"Zhang","suffix":""},{"id":70576095,"identity":"f5fca33b-a927-49f2-b5eb-be03f27c5e98","order_by":2,"name":"Fanru Shen","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fanru","middleName":"","lastName":"Shen","suffix":""},{"id":70576096,"identity":"b0c5444d-807d-410c-a3be-e155d7b3f6ad","order_by":3,"name":"Yuan Shi","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Shi","suffix":""},{"id":70576097,"identity":"ef3415fd-53e7-480f-accb-3d4c21858cd8","order_by":4,"name":"Sailiang Liu","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sailiang","middleName":"","lastName":"Liu","suffix":""},{"id":70576098,"identity":"5e918f7a-4c0f-416f-967f-e0ed06888c80","order_by":5,"name":"Yihua Jin","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yihua","middleName":"","lastName":"Jin","suffix":""},{"id":70576099,"identity":"1f6a11e0-f668-415a-bd4c-62a73a354a12","order_by":6,"name":"Ming Zhong","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Zhong","suffix":""},{"id":70576100,"identity":"346105df-7a67-4643-825b-fa56c9e5ac01","order_by":7,"name":"Yuqi Qiao","email":"","orcid":"","institution":"Renji Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuqi","middleName":"","lastName":"Qiao","suffix":""},{"id":70576101,"identity":"fdd3a610-712c-4eca-8bb2-e1c374f6452b","order_by":8,"name":"Minhao Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYBAC9mYGNjhH4oOBjR1BLTyHkbRIzihISyas5QCSFmmeD4cYGwhqYWd/9uhGhV2evHvzwds2BgeYGdgPH92AVwszj7lxzpnkYsMzx5Ktcwzu8DHwpKXdwKfFnpmHTTq3jTlx44wcM+kcg2fMDBI8Zni18DCzP5PO/VcP0WJhcJixgbAWBjPp3IbDifMlgFoYiNPCA3TPseOJG3iOJVv2GKQlsxHyCw//8WfSOTXVifPbmw/e+PHHxo6f/fAxvFrgwOAAlMGGTxUKkG8gWukoGAWjYBSMNAAA6ORE/8AqlngAAAAASUVORK5CYII=","orcid":"","institution":"Renji Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Minhao","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2021-12-05 10:29:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1142302/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1142302/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":17275463,"identity":"767b1803-d63e-4759-9dd3-e8b672694fa5","added_by":"auto","created_at":"2022-01-13 08:29:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":436682,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1142302/v1/9b5a7ed5-2a04-48ef-8583-211392cb8817.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eLonger Diagnosis-surgery Duration Is Associated With an Increased Risk of Early Postoperative Complications for Crohn's Disease: A Retrospective Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCrohn\u0026rsquo;s disease is an immune-mediated inflammatory bowel disease characterized by chronic skip lesions that can affect any part of the gastrointestinal tract, leading to bowel damage and disability\u003csup\u003e1\u003c/sup\u003e. As a global disease, its worldwide incidence and prevalence are steadily increasing with time\u003csup\u003e2\u003c/sup\u003e. Since the 1980s, the introduction of biological therapies such as monoclonal antibody against tumor necrosis factor (TNF) and vedolizumab changed the paradigm of treatment, leading to improved response and remission in patients\u003csup\u003e3\u0026ndash;5\u003c/sup\u003e. Though the risk of surgery in patients with Crohn\u0026rsquo;s disease shows a decreasing trend thanks to advances in pharmacotherapy, about 50% of patients develop complications refractory to medical therapy and will still require surgery within 10 years after diagnosis \u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAccording to the literature, early postoperative complications(ePOCs) could occur in up to 37.5% of CD patients after surgery\u003csup\u003e7\u0026ndash;13\u003c/sup\u003e. Therefore, numerous studies have tried to explore the risk factors related to ePOCs which include low albumin level, penetrating disease, laparoscopic approach, preoperative exposure to steroids\u003csup\u003e7\u0026ndash;13\u003c/sup\u003e. On the one hand, data remain conflicting regarding on some variables such as preoperative use of anti-TNF agents\u003csup\u003e8\u0026ndash;13\u003c/sup\u003e; on the other hand, many variables are not included in the preexisting studies such as the diagnosis-surgery duration and some preoperative biological data. Therefore, better knowledge of risk factors for ePOCs of CD would help to define a high-risk population where prevention for postoperative complications would be beneficial.\u003c/p\u003e \u003cp\u003eThe purpose of this study was to reliably identify incidence and risk factors of ePOCs after surgery for CD in a retrospective cohort from a high-volume tertiary center to improve postoperative outcomes.\u003c/p\u003e "},{"header":"Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003cdiv id=\"Sec3\" class=\"Section3\"\u003e \u003ch2\u003e2.0 Patient selection\u003c/h2\u003e \u003cp\u003eThis was a single-center retrospective study based on a database of 97 patients who underwent surgical resection for primary or recurrent Crohn's disease between January 2010 and September 2019. Patients pathologically diagnosed with Crohn's disease intraoperatively were included. Exclusion criteria were surgeries without pathological examination such as perianal surgery and abscess drainage alone, and missing or invalid data precluding analysis. 97 patients were eligible for analysis after these exclusion criteria were applied. This study was approved by Renji hospital\u0026rsquo;s research and ethics committee (KY2019-180).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Data collection\u003c/h2\u003e \u003cp\u003eData were retrieved in a standardized format by expert gastroenterologists from Renji hospital medical records. Demographic data (age, sex, age at diagnosis, diagnosis-surgery duration), clinical data (disease location and behavior according to the Montreal classification\u003csup\u003e14\u003c/sup\u003e, presence of perianal manifestation and multiple lesions, history of intestinal resection and anal fistula surgery, and the indications for surgery), data on medication (steroids, IFX, 5-ASA, MTX, Azathioprine, Tacrolimus use within 2 months before surgery and their use history), preoperative laboratory testing (including serum hemoglobin, leukocyte, platelets, C-reactive protein, erythrocyte sedimentation rate, albumin, prealbumin, alanine transaminase, glutamic-oxalacetic transaminase, gamma-glutamyl transpeptidase, direct bilirubin, total bilirubin, urea, creatinine, uric acid, Na ion, K ion, procalcitonin levels), and operative data (emergency surgery, surgical approach, anastomotic configuration, length of hospital stay) were collected. All operations were performed by specialized surgeons from colorectal surgery department in Renji Hospital. And the surgical techniques (including surgery approach, anastomosis vs. stoma, etc.) were decided on a per-patient basis and left to the discretion of the surgeon based on patient\u0026rsquo;s disease characteristics and intra-operative findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Evaluated outcomes\u003c/h2\u003e \u003cp\u003eSurgical outcome was determined by postoperative complications and follow-up. Early postoperative complications(ePOCs) were defined as any deviation from the normal postoperative course within 30 days after surgery, and classified into three categories; (i) intra-abdominal septic complications (IASC)(including abdominal abscess and anastomotic leak confirmed radiologically), (ii)extra-abdominal septic complications(including wound infection, pneumonia and septic shock) and (iii)non-septic complications(including enterocutaneous fistula, hemorrhage, bowel obstruction, gastric retention, thrombosis, malnutrition, anemia). Specifically, abdominal abscess was defined as an abdominal mass or an area of localized abdominal tenderness in a feverish patient, confirmed by radiological evidence; bowel obstruction was defined as bowel dysfunction associated with clinical manifestations such as abdominal distention or vomiting. Data on aforementioned ePOCs were collected in a standardized format by appropriate laboratory tests and/or imaging modalities and were reviewed in detail. The severity of ePOCs was graded as I, II, III, IV, or V, according to the Dindo\u0026ndash;Clavien classification\u003csup\u003e15\u003c/sup\u003e. Grades I, II were considered to be minor complications while grades III-V were considered to be major complications. Furthermore, the length of hospital stay was also noted.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eThe SPSS program version 21 was used for data analysis. Categorical variables were represented as the number (percentage). The primary endpoint was the occurrence of ePOCs. Normality of distribution for quantitative variables was evaluated using the Kolmogorov-Smirnov tests. Normally distributed variables were described as mean value (\u0026plusmn;standard deviation), whereas non-normally distributed ones were presented as median (25th -75th interquartile range [IQR]). In order to identify the risk factors of ePOCs, univariate and multivariate analyses were performed to examine the relationship between the occurrence of ePOCs and variables related to the patient characteristics and their clinical parameters. Univariate analysis was conducted using Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test to compare categorical variables, as appropriate. All variables associated with \u003cem\u003eP\u003c/em\u003e values \u0026lt;0.1 were included in a binary logistic regression model, expressed as the odds ratio (OR) (95% confidence interval (CI)). All P-values were 2-sided and P-values \u0026lt;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv class=\"Section2\" id=\"Sec8\"\u003e\n \u003ch2\u003e3.0 Demographic and clinical characteristics\u003c/h2\u003e\n \u003cp\u003eFrom January 2010 and September 2019, 97 patients underwent surgeries for CD. Their demographic and clinical characteristics at the time of surgery are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Our population had a median age of 43 years (IQR 37-52 years), and included 64 male patients (66.0%). According to Montreal classification, the majority of patients (n=57, 58.8%) were diagnosed with CD between 17-40 years old(A2); 34 patients (35.1%) presented with disease localized in ileum(L1) and 26 patients (26.8%) had colon(L2) involvement only; clinical disease behavior was non- stricturing/non-penetrating in 22 patients (22.7%), stricturing in 41 patients (42.3%) and penetrating in 34 patients (35.0%). Perianal lesion was detected in 27(27.8%) cases. 15(15.5%) patients had a history of abdominal surgery. 13(13.4%) patients had previously undergone anal fistula surgery.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec9\"\u003e\n \u003ch2\u003e3.1 Medications\u003c/h2\u003e\n \u003cp\u003eThe medication history and preoperative (within 2 months before surgery) medical treatment are specified in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. For patients\u0026rsquo; medication history, 34 (35.1%) patients had been treated with steroids, including either systemic steroids or budesonide. 41 (42.3%) patients had received 5-aminosalicylic acid, and 23 (23.7%) patients had received azathioprine in their medical records; fewer patients had been treated with infliximab (8, 8.2%), methotrexate (2, 2.1%), tacrolimus (3, 3.1%). As for preoperative medical treatment, 19 patients had received steroids within 2 months before surgery, and 26 (26.8%) patients had been treated with 5-aminosalicylic acid (with 1 on infliximab, 9 on azathioprine and 1 on tacrolimus).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003e3.2 Preoperative laboratory testing\u003c/h2\u003e\n \u003cp\u003eLaboratory tests at the time of surgery are detailed in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. In the routine blood tests, the median leukocyte count was 7390/mm3 (5100\u0026ndash;12500), the mean hemoglobin level was 11.2g/dl, and the median platelet count was 245\u0026times;109/L (195\u0026ndash;341). The median C-reactive protein level at surgery was 6.38 (1.73-21.30) mg/dl while the median ESR level was 17(10.25-37.5) g/dl, and the median prealbumin level was 155.85mg/L (105.73-221.75). A minority of patients (n=19, 19.6%) had poor preoperative nutritional status defined as preoperative serum albumin \u0026lt;30 g/dL. For liver function related index, the median serum level of ALT, AST, and GGT was 11(7.0-18.3), 14(11.0-17.25), and 17.3(10.45-32.25) U/L, respectively (3.9 and 9.6 umol/L on median serum direct and total bilirubin). For renal function test, the median serum creatine and uric acid level was 59.1(47.5-71) and 216.45(96.49), respectively. Data regarding serum procalcitonin level were only collected in 28 cases, most of which were \u0026gt;0.02 ng/ml (n=22, 75.9%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003e2.3 Surgical data\u003c/h2\u003e\n \u003cp\u003eThe median duration from diagnosis to surgery was 4(0-25.5) months, and more than 41.2% patients did not undergo surgery until 6 months after diagnosis. Emergency surgery was performed in 23(23.7%) cases; laparoscopic surgery in 43(44.3%) patients, and anastomosis was preferred in a majority of patients (n=90, 92.8%). The indications for surgery were obstruction in 40 (41.2%), fistula in 10 (10.3%), perforation in 18(18.6%), bleeding in 6(6.2%) and medication-refractory disease in 5(5.2%) cases. The median postoperative hospital stay was 10 days (7\u0026ndash;13).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec12\"\u003e\n \u003ch2\u003e3.4 ePOCs\u003c/h2\u003e\n \u003cp\u003eOverall, 42 ePOCs were observed in 33 patients (34.0%), including 25(25.8%) minor complications (Dindo-Clavien grade I/II) and 8(8.2%) major complications (Dindo-Clavien grade III-V) (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Multiple complications occurred in 6 patients (6.2%). Among all the ePOCs, wound infection was the most common ePOC (n=13, 13.4%). IASCs were recorded in 11 patients (11.3%), including abdominal abscess (n=9, 9.3%) and anastomotic leak (n=2, 2.1%). Extra-Abdominal septic complications occurred in 19 patients (19.6%). Bowel obstruction was the most frequent non-septic complication (5.2%), while postoperative hemorrhage and malnutrition were recorded in 1 patient (1.0%). Other non-septic complications included enterocutaneous fistula (1.0%), gastric retention (2.1%), and anemia (1.0%). No thromboembolic complications were observed. One patient died during the 30-day postoperative period. The median length of postoperative hospital stay was 10 days (7\u0026ndash;13), which is significantly correlated with the occurrence of postoperative complications(P\u0026lt;0.001).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003e3.5 Univariate Analyses of the Risk Factors of ePOCs\u003c/h2\u003e\u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003e3.5.1\u003c/strong\u003e \u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eDemographic and clinical variables.\u003c/span\u003e The results of univariate analyses of the risk factors for overall ePOCs in 97 patients undergoing surgery for CD are reported in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. None of the studied demographic variables was significantly associated with the occurrence of postoperative complications. Significant differences (P\u0026lt; 0.001) were found in the postoperative complication rate between different disease behavior groups according to Montreal Classification. Higher complication rate (52.0%) was observed in penetrating disease compared to non-penetrating disease (27.8%) (P=0.027). Patients with multiple lesions had significantly higher percentage of ePOCs (51.4% vs. 23.3%, P=0.005).\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003e3.5.2\u003c/strong\u003e \u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eMedications.\u003c/span\u003e Steroid use was associated with a higher incidence of ePOCs (41.2%), although statistical significance was not reached (P=0.274); similarly, the administration of steroids within 2 months before surgery showed insignificantly higher percentages (42.1%) of complications(P=0.407). Infliximab use (25% vs. 34.8%, P=0.71) and preoperative infliximab exposure(P=1.00) were not risk factors for ePOCs. Analyses concerning other therapeutic regimens revealed no significant differences in ePOC rates.\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003e3.5.3\u003c/strong\u003e \u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eLaboratory parameters.\u003c/span\u003e Patients with serum platelet count \u0026lt;300(*1000/mm3) had a significant higher rate of ePOCs (39.7% vs. 19.4%, P=0.0 49). And there was a significant positive correlation between CRP levels of \u0026gt;10 g/L and ePOCs (23.6% vs. 47.6%, p=0.014). Other biological variables associated with significantly higher rates of ePOC include prealbumin level\u0026lt;174 mg/L(P=0.04), GGT level \u0026gt;10 U/L(P=0.01) and serum sodium ion level \u0026lt;139 mmol/L(P=0.008).\u003c/p\u003e\n \u003c/span\u003e \u003cspan\u003e\n \u003cp\u003e\u003cstrong\u003e3.5.4\u003c/strong\u003e \u003cspan class=\"BoldItalic\" name=\"Emphasis\" type=\"BoldItalic\"\u003eSurgical variables.\u003c/span\u003e The diagnosis-surgery duration exceeding 6 months is significantly correlated with a higher percentage of ePOCs(P\u0026lt;0.001). 7 patients (16.3%) undergoing laparoscopic surgery experienced postoperative complications, compared with 26 patients (48.1%) undergoing open surgery(P=0.001). There is no significant correlation between the indication for surgery and the occurrence of ePOCs(P=0.691).\u003c/p\u003e\n \u003c/span\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec14\"\u003e\n \u003ch2\u003e3.6 Multivariate Analyses of the Risk Factors of ePOCs\u003c/h2\u003e\n \u003cp\u003eFactors affecting ePOCs incidence at a significance level of \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.1 in univariate analysis were inserted into a binary logistic regression model (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Diagnosis-surgery duration exceeding 6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e(odds-ratio [OR]=6.74; confidence interval [CI] 95%[1.58-28.71], P=0.01), serum GGT level \u0026gt;10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031)were identified as independent risk factors for the ePOCs.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCD Patients\u0026rsquo; Baseline Information and univariate analysis of the risk factors for ePOCs (n=97)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eClinical Pathological Factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (yr), m (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e43(37-52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e64(66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.918\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMontreal Classification-Age at diagnosis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.887\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e57(58.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e38(39.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMontreal Classification- Location, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e34(35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e26(26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e36(37.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eL4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMontreal Classification-Behavior, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e22(22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e41(42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e34(35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerianal manifestations, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e27(27.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.571\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiple lesions, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e37(38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious abdominal surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e15(15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.595\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious CD-related surgical resection, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e13(13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious anal fistula surgery, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e13(13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrevious medication history, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSteroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e34(35.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIFX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e8(8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5-ASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e41(42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMethotrexate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e2(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.546\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAzathioprine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e23(23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTacrolimus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3(3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.266\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative lab index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeukocytes (/mm\u003csup\u003e3\u003c/sup\u003e), m (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7.39(5.1-12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10.0, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e31(33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHemoglobin, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e112.3(21.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;110.0, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e40(41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelets (*1000/mm\u003csup\u003e3\u003c/sup\u003e), m (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e245(194.75-340.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;300, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e63(64.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC-reactive protein (g/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e6.38(1.73-21.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e42(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eESR (mm/h), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e17(10.25-37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e36(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrealbumin(mg/L),m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e155.85(105.73-221.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;174\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e48(53.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAlbumin(g/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e35.2(31.05-40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19(21.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eALT(U/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e11(7.0-18.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.720\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAST (U/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e14(11.0-17.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e16(17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.618\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGGT (U/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e17.3(10.45-32.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e68(76.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.010\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect bilirubin (umol/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3.9(2.4-5.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e65(72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal bilirubin (umol/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e9.6(5.5-12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e23(25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.541\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrea (mmol/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4.4(3.07-5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e22(24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.930\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCreatinine (umol/L), m(IQR) median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e59.1(47.5-71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e22(24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUric acid(umol/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e216.45(96.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e23(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.794\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNa+(mmol/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e139(137-141)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e49(51.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eK+ (mmol/L), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e3.9(3.4-4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e32(33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.796\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProcalcitonin(ng/ml), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.06(0.02-2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e22(75.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.646\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative medical treatment (within 2 months before surgery), n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSteroids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e19(19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.407\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIFX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5-ASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e26(26.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMethotrexate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e9(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.714\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAzathioprine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e༏\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTacrolimus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1(1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiagnosis-surgery duration (months), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e4(0-25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;6, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e40(41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEmergency operation, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e23(23.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.273\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic surgery, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e43(44.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnastomosis, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e90(92.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndications for surgery, n(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.691\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e40(41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e10(10.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePerforation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e18(18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e6(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication- refractory diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5(5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e18(18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLength of stay in hospitals (days), m(IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e10(7-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab2\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eePOCs in 97 postoperative CD patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of patients having ePOCs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33(34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eePOC cases (\u003cem\u003en\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiple complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraabdominal septic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11(11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbdominal abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnastomotic leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eExtra-abdominal septic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19(19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWound infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(13.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSeptic shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-septic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEnterocutaneous fistula\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBowel obstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGastric retention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalnutrition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDeath\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClavien- Dindo Classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMild complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25(25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGrade I\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGrade II\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18(18.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8(8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGrade III\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGrade IV\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eGrade V\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable border=\"1\" id=\"Tab3\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMultivariate Analysis of the Risk Factors of ePOCs (n= 97)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRisk Factors\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOdds ratio (95%CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP Value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMultiple lesions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.57(0.62-10.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eClinical disease behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon- penetrating disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePenetrating disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.44(0.33-6.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC-reactive protein(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.15(0.78-12.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlatelet count (*1000/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;300\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.74(1.58-28.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGGT(U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.22(1.23-68.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNa+ (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41(0.11-1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiagnosis- surgery duration(months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026gt;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.07(1.10-15.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgical approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLaparoscopic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34(0.86-1.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSurgical resection for CD patients is correlated to high ePOC risks. And some serious postoperative complications such as intra-abdominal septic complications occur more frequently in CD than other diseases \u003csup\u003e16\u003c/sup\u003e, necessitating evaluation of the frequency and risk factors of ePOCs for CD.\u003c/p\u003e \u003cp\u003eIn this retrospective study, 34.0% patients experienced at least one ePOC, wound infection being the most frequent complication. This incidence is comparable with the current literature, ranging from 21\u0026ndash;37%\u003csup\u003e7\u0026ndash;13\u003c/sup\u003e. The mortality rate was 1.0% and IASCs were recorded in 11.3% cases, in line with previous studies\u003csup\u003e8\u0026ndash;12\u003c/sup\u003e. Numerous studies examined the incidence of ePOCs. A retrospective multi-center study(\u003cem\u003en\u003c/em\u003e=231) of an adult cohort in three countries (Japan, Brazil and Italy) reported an overall ePOCs of 24%. Among 55 reported complications, 12% were intra-abdominal septic complications including anastomotic leakage (8%) and intra-abdominal abscesses (4%). Blood transfusion and perforating disease were independent significant risk factors for overall complications and IASCs, respectively\u003csup\u003e8\u003c/sup\u003e. Another more recent retrospective study in Europe evaluated the risk of postoperative complications in 199 CD patients. 62 (31%) patients experienced at least some kind of ePOCs and IASCs occurred in 34 patients (17%). One patient (0.5%) died from septic shock following proctocolectomy. A bivariate analysis revealed that surgical anastomosis and preoperative hemoglobin level of \u0026lt; 10 g/dl were associated with an increased postoperative IASC rate\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDue to high rates of ePOCs for CD surgeries, preoperative risk evaluation of complications seems pivotal to patient optimization for surgery \u003csup\u003e17\u003c/sup\u003e. In our study, A diagnosis-surgery duration\u0026gt;6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e(odds-ratio [OR]=6.74; confidence interval [CI] 95%[1.58-28.71], P=0.01), serum GGT level \u0026gt;10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031) were significantly associated with a higher risk for ePOCs in a binary regression.\u003c/p\u003e \u003cp\u003eAs a progressive disease, CD results in cumulative bowel damage over time, leading to irreversible complications\u003csup\u003e18\u003c/sup\u003e. In a population-based study on the CD progression, about 19% of patients had already experienced penetrating or stricturing complications within the first 3 months of diagnosis, but complications occurred in 50% of patients within 20 years after diagnosis\u003csup\u003e19\u003c/sup\u003e, indicating longer disease duration is associated with increasing disease severity. Therefore, rapid and early intervention including medications and surgery may effectively prevent CD progression so as to reduce the risk of adverse complications and healthcare burden\u003csup\u003e20\u003c/sup\u003e. Shorter disease duration is related to a higher response rate to biologic agents in CD patients\u003csup\u003e21\u003c/sup\u003e. Issues regarding on the safety of early surgical intervention for CD patients, however, are still a subject to debate without a clear consensus. Recently published data from a retrospective study with 153 CD patients undergoing elective ileocolic resection in a Greek tertiary center revealed that disease duration was not an independent predictor for POCs: complication rates in those who went on surgery \u0026lt;5 years, in 5-10 years and \u0026gt;10 years after diagnosis were 16.1%, 13.9% and 36.4%, respectively, with no intergroup differences in the incidence of POCs\u003csup\u003e12\u003c/sup\u003e. Our series, however, reported a significant correlation between diagnosis-surgery duration \u0026gt;6 months and ePOCs, in accordance with some previous large studies. For example, a retrospective study in France, concerning 592 consecutive patients who underwent surgery for CD, reported that CD duration \u0026gt;2 years is significantly associated with ePOCs(P=0.01) in univariate analysis\u003csup\u003e10\u003c/sup\u003e. We believe that our findings augment the evidence for the negative effect of long diagnosis-surgery duration on the postoperative course of CD patients. Therefore, we recommend early surgery for eligible patients in order to avoid postoperative complications. Elżbieta \u003cem\u003eet al.\u003c/em\u003e examined the relationship between CD duration and CARD15 expression, one of the susceptibility genes in CD, and found a significantly higher peripheral mRNA level of the CARD15 in patients with disease duration between 12 and 60 months, compared to patients whose disease duration was \u0026lt;12 months \u003csup\u003e22\u003c/sup\u003e. We speculated that higher CARD15 expression over longer disease duration modified the disease behavior\u003csup\u003e23\u003c/sup\u003e, making it more complicated, thus leading to a higher rate of ePOCs. And further studies are needed to precisely explore the safety of early surgical intervention and its ability to prevent disease progression in CD.\u003c/p\u003e \u003cp\u003eIt is important to understand how modifiable factors, especially pre-operative lab parameters, affect outcomes after surgical interventions, so that we can identify high-risk CD population for preoperative optimization. Current data concerning these aspects are, however, relatively scarce, focusing mainly on hemoglobin, CRP and albumin level\u003csup\u003e9,10,12\u003c/sup\u003e. Therefore, one of the unique aspects of our study is the evaluation of numerous possible preoperative lab data. In multivariate analysis, serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e and serum GGT level \u0026gt;10U/L were found to be independent risk factors of ePOCs. Low platelet counts can serve as an indicator for active CD\u003csup\u003e24\u003c/sup\u003e, which also helps to explain the correlation between low serum platelet count and a higher risk of ePOCs. On the other hand, Jessika \u003cem\u003eet al.\u003c/em\u003e\u003csup\u003e25\u003c/sup\u003e determined that the presence of liver test abnormalities, including gamma-glutamyl transpeptidase, was identified as an indicator for complicated CD(HR 2.6, p \u0026lt; 0.0001). And elevated gamma-glutamyl transpeptidase itself suggests abnormal liver function, which might account for a higher risk of ePOCs. Therefore, according to our study, CD patients who are going to be operated but with serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e or gamma-glutamyl transpeptidase level \u0026gt;10U/L can be better prepared. Abnormal lab values need to be corrected in these patients to improve postoperative safety.\u003c/p\u003e \u003cp\u003eAnti-TNF-alpha agents have been used in the treatment of CD, and their efficacy on CD progression has been well demonstrated\u003csup\u003e3\u0026ndash;5\u003c/sup\u003e. Early initiation of infliximab within the first 2 years of diagnosis reduces the rate of surgery\u003csup\u003e26\u003c/sup\u003e. However, given its potential impact on wound healing and immunosuppressive properties, a crucial concern is whether patients undergoing major abdominal surgery after anti-TNF drug exposure are at increased risk of early postoperative complications\u003csup\u003e27\u003c/sup\u003e. In our series, previous exposure to anti-TNF agents in CD patients was not a risk factor for ePOCs, in line with most studies. A Mayo Clinic study\u003csup\u003e28\u003c/sup\u003e supported this idea by illustrating no association between infliximab use and early complications after abdominal surgery for CD. A Los Angeles study\u003csup\u003e27\u003c/sup\u003e revealed a higher but statistically insignificant rate of adverse outcomes in anti-TNF detectable versus undetectable group. Another Canadian retrospective case-control study \u003csup\u003e29\u003c/sup\u003e compared postoperative outcomes of CD patients with or without exposure to anti-TNF agents within 180 days of abdominal surgery, but no intergroup difference was found. The most recent, prospective multicentric literature that included serum drug level measures at time of surgery found no association between preoperative exposure to anti-TNF and postoperative complications\u003csup\u003e30\u003c/sup\u003e. Some studies, however, reached contrary conclusions. Antoine \u003cem\u003eet al.\u003c/em\u003e \u003csup\u003e10\u003c/sup\u003e in 2018 found that preoperative anti-TNF therapy was a predictor of morbidity after surgery for ileocolonic CD. Some meta-analyses indicated that preoperative anti-TNF exposure was a risk factor of POCs in CD patients\u003csup\u003e31\u0026ndash;34\u003c/sup\u003e. Most of the studies have been criticized for not being able to control crucial confounding factors, such as disease severity, nutritional status as well as preoperative corticosteroid use, which make conclusions less convincing: elevated postoperative complication rates may just be a reflection of disease severity and a higher likelihood of poor nutritional status, but not a direct effect of preoperative anti-TNF exposure. More valid data are needed to confirm our results.\u003c/p\u003e \u003cp\u003eOur study presents certain limitations. First, the retrospective design indicates that data can only be passively retrieved from patients\u0026rsquo; medical records. Therefore, some data are incomplete or even not collected at all, including procalcitonin levels, configuration of anastomosis (end-to-end vs. side- to-side), patients\u0026rsquo; smoking status, BMI values, which are presumable risk factors for ePOCs. Secondly, the sample size(n=97) is not big enough due to the single-center design, which may lead to insufficient size of some subgroups (such as patients with anti-TNF preoperative exposure). Thus, detection of differences may be more difficult and some risk factors for ePOCs might be precluded. Finally, we choose patients from a high-level center that managed CD patients with complicated and severe conditions, suggesting poorer prognosis than other patients despite well-trained and experienced surgeons and multidisciplinary teams. However, we believe that our study adds more new and convincing evidence of risk factors of ePOCs in CD patients.\u003c/p\u003e \u003cp\u003eIn conclusion, the incidence of ePOCs was 34.0% among CD patients undergoing surgical resection. Diagnosis-surgery duration exceeding 6 months, serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e and serum GGT level \u0026gt;10U/L were identified as independent risk factors for the ePOCs. And preoperative anti-TNF exposure was not associated with an elevated ePOC rate.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eOverall, we summarized that the diagnosis-surgery duration exceeding 6 months, serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e, and serum GGT level \u0026gt;10U/L were associated with an increased risk of ePOCs. Preoperative exposure to anti-TNF agents were not associated with a higher risk of ePOCs. As physicians, the interest of the patient should always be well considered, by reducing the diagnosis-surgery duration, which means to get surgery done sooner, will significantly reduce the early postoperative complications, pain and financial burden of the patient.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eAll methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital. Informed consents were obtained from all subjects involved in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. The data are not publicly available due to some containing information that could compromise participant privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe work was supported by the Cultivation Clinical Research Grants from Renji Hospital affiliated to Shanghai Jiao Tong University School of Medicine (PYIII20-14 to Yumin Hao).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e XC and YM participated in the conception, design, drafting of the study protocol, recruitment of participants. SZ, SL and YJ were responsible for data acquisition. XC and SZ participated in the analysis and interpretation of the data. FS, YS and YQ contributed to the revising of the paper. YM and MZ were responsible for the final approval of the version to be published. And all authors agree to be accountable for all aspects of the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRoda G, Chien Ng S, Kotze PG, et al. Crohn's disease. \u003cem\u003eNat Rev Dis Primers\u003c/em\u003e 2020; \u003cstrong\u003e6\u003c/strong\u003e(1): 22.\u003c/li\u003e\n\u003cli\u003eMolodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. \u003cem\u003eGastroenterology\u003c/em\u003e 2012; \u003cstrong\u003e142\u003c/strong\u003e(1): 46-54 e42; quiz e30.\u003c/li\u003e\n\u003cli\u003eColombel JF, Sandborn WJ, Reinisch W, et al. 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The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study. \u003cem\u003eAliment Pharmacol Ther\u003c/em\u003e 2004; \u003cstrong\u003e19\u003c/strong\u003e(7): 749-54.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Crohn’s disease, diagnosis-surgery duration, postoperative complications, risk factors, retrospective study","lastPublishedDoi":"10.21203/rs.3.rs-1142302/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1142302/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eEarly postoperative complications(ePOCs) frequently occur in Crohn’s patients after surgery. The risk factors of ePOCs for Crohn’s disease (CD), however, remain controversial. We aimed to assess the incidence and risk factors of ePOCs in CD patients after surgical resection.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe retrospective study was conducted on 97 patients undergoing surgeries between January 2010 and September 2019 for Crohn’s disease in a tertiary hospital in China. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eIn total, 33 patients (34.0%) experienced ePOCs, including 11 intra-abdominal septic complications (11.3%) and 1 postoperative death (1.0%). Severe complications (Dindo–Clavien III–IV) were seen in 8 patients (8.2%). In multivariate analysis, diagnosis-surgery duration exceeding 6 months(odds-ratio [OR]=4.07; confidence interval [CI] 95%[1.10-15.09], P=0.036), serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e(odds-ratio [OR]=6.74; confidence interval [CI] 95%[1.58-28.71], P=0.01) and serum gamma-glutamyl transpeptidase(GGT) level \u0026gt;10U/L(odds-ratio [OR]=9.22; confidence interval [CI] 95%[1.23-68.99], P=0.031)were identified as independent risk factors for ePOCs. Preoperative exposure to anti-tumor necrosis factor (TNF) agents (P=1.00) were not associated with a higher risk of ePOCs. 34.0% of CD patients developed ePOCs after surgical resection.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Diagnosis-surgery duration exceeding 6 months, serum platelet count \u0026lt;300*1000/mm\u003csup\u003e3\u003c/sup\u003e, and serum GGT level \u0026gt;10U/L were associated with an increased risk of ePOCs. Preoperative exposure to anti-TNF agents were not associated with a higher risk of ePOCs.\u003c/p\u003e","manuscriptTitle":"Longer Diagnosis-surgery Duration Is Associated With an Increased Risk of Early Postoperative Complications for Crohn's Disease: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-12-20 15:44:45","doi":"10.21203/rs.3.rs-1142302/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0ee58dba-991e-4120-b592-d139db135ca3","owner":[],"postedDate":"December 20th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":9261109,"name":"Gastroenterology \u0026 Hepatology"}],"tags":[],"updatedAt":"2022-01-13T08:29:18+00:00","versionOfRecord":[],"versionCreatedAt":"2021-12-20 15:44:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1142302","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1142302","identity":"rs-1142302","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}